Healthcare Provider Details

I. General information

NPI: 1790728012
Provider Name (Legal Business Name): HOMER A FERGUSON, JR, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 N ILLINOIS
SWANSEA IL
62226
US

IV. Provider business mailing address

3990 N ILLINOIS
SWANSEA IL
62226
US

V. Phone/Fax

Practice location:
  • Phone: 618-277-1130
  • Fax: 618-277-6651
Mailing address:
  • Phone: 618-277-1130
  • Fax: 618-277-6651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License Number
License Number State

VIII. Authorized Official

Name: HOMER A FERGUSON II
Title or Position: OWNER
Credential: MD
Phone: 618-277-1130